Saturday, March 3, 2012

One more year? - Family Medicine Residency Training

A few weeks ago, the American Board of Family Medicine was approved to sponsor a pilot of 4-year family medicine residency programs. Leaders in family medicine organizations have been exploring moving family medicine training to 4 years for some time and, starting in July 2013, programs that apply and are accepted will have the opportunity to offer 4 years of residency.

Why this change now? In the 2011, for the second consecutive year in more than a decade, more students are choosing to enter family medicine (1). When this debate started, interest in family medicine had reached an all time low (2). Is this debate to extend residency training now irrelevant with re-emerging student interest? I would argue not. As organizations and leaders in family medicine, our goal is not primarily to promote our specialty but to best serve our patients and their health. So our question then is does a 4-year family medicine residency better serve our patients balancing quality of the physicians trained with the number of physicians and access to those physicians?

To date, only one family medicine residency program has moved to a mandatory 4-year curriculum. As part of the P4 innovation program, Middlesex FMR (in CT) switched in 2006 to a 4 year program and have found, based on preliminary results, that student application rates to the residency have increased, clinical outcomes from the clinic have improved, resident satisfaction rate has improved and financial success of the clinic has been enhanced (3). Other P4 programs have offered optional 4 year tracks but the number of residents who have selected these tracks to date has been too small to appropriately report results. Outside of the P4 programs, Oregon Health and Sciences University plans to move to a 4 year curriculum starting this July (4).

Proponents of the 4-year family medicine residency model advance multiple benefits of the additional year of training:

Increasing complexity of health care: Today's family physicians enter into an increasing complex medical system with increasing complex health needs. The average person is living longer with more chronic diseases and learning how to care for these problems will require more training. The scope of family physicians has been decreasing in recent years (5) and for residency graduates to feel confident in practicing comprehensive care, additional training would be beneficial. Furthermore, not only is the science of medicine growing more complex but the art of medicine is also expanding. Today's family physician must be trained in practice management/transformation, quality improvement, research, leadership skills, cultural competency and more - all of which currently sit on the back burner with so many competing medical curricular items.

Potential for flexibility: A 4th year allows for more elective time and allows for residents to develop an "Area of Concentration." This could potentially reduce the need for fellowship training and reduce the artificial transition between residency and fellowship.

New work rules: New work rules implemented in July 2011 again effectively reduce residency work hours and reduce residents' experience and training.

Decreased preparation of interns: Many of suggested that today's interns are less prepared than those of a decade ago. Because of wide range of issues, an incoming resident today is less likely to have had adequate hands-on training.

There are significant concerns that need to be addressed though before family medicine dives headlong into 4 year residency training:

Student interest: while I dismissed student interest earlier in favor of patient value, it remains an important issue. I brought this issue up at a recent AAFP commission meeting and it was suggested that I was being impertinent for considering the specialty's numbers above the needs of the nation's health needs. In reality though, it doesn't do any good if we have great training programs if we don't have any students and residents to fill those training programs. Family medicine leaders points to numbers that show that each year a growing number of students, residents and faculty support 4 year training programs. However, this number remains a minority (<50%) and the fact is a growing minority is still a minority whether or not it is growing.

Law of diminishing returns: I learned this concept in health economics where I learned that more is not always better. Yes, an additional year of training is generally always better but what about a 5th year of training? Or a 6th? Each progressive year can add something in training and comprehesiveness but what we gain may not balance out the other disadvantages. Our northern neighbour, Canada, does FM residency training in 2 years - is there something we're missing?

Workforce challenges: Will adding a year of training exacerbate workforce issues? First, there's the issue already discussed of student interest. But we also need to consider that there will be a transitional period when we are producing fewer residents because they are in training longer. Furthermore, there is the question of whether existing programs will accept smaller classes to accommodate the increased number of residents present overall. For example, Middlesex, the only 4-year program to date, went from being a 8-8-8 program to a 6-6-6-6 program.

Logistical challenges - can residency programs get funding and accreditation?

I don't know if we should move to mandatory 4-year residency training in family medicine. Personally, as a medical student currently in the residency application process, I am seriously considering programs that offer 4 year training. But, I believe that serious and open-minded discussions and research must take place to decide if this is the best move for our specialty and, more importantly, for our patients. Discussions must take place with all stakeholders (family medicine organizations, faculty, residents, students and the general community/people we serve) and pilot projects with exemplary research methodology must take place. We have reached an important juncture and what we decide now may have significant reverberations for our patients and their health.

(1) AAFP News Today. 2011 Match Results Again Spotlight Family Medicine Gains. March 17, 2011.
(2) Saultz JW. Is it time for a 4-year family medicine residency? Family Medicine2004;36(5):363-6.
(3) Douglass AB et al. Implementation and Preliminary Outcomes of the Nation's First Comprehensive 4-year Residency in Family Medicine. Family Medicine2011;43(7):510-3.
(4) OHSU Family Medicine Residency Program. Website
(5) Upcoming JABFM policy brief series on care for children, maternity care and care for women's health by family physicians.

1 comment:

Particularly as a fourth year medical student, I have been considering the value of adding this extra year. After all, it makes sense that more time spent in training would certainly equate with better experience. Under this logic, why not make it say 5 years, or 7 years, or 10 years in residency? Pardon my cynicism for the moment.

But truly, I can appreciate the considerations for adding an extra year - principally in relation to the work hour restrictions and the ever-expanding mountain of information needed to digest in medicine.

The greater question I have is more in incent. Would adding this extra year disincentivize medical students from entering family medicine? Would these students be swayed by the internal and emergency medicine programs that still promise some modicum of primary care, and only require an additional three years of training?

My generation of medical students places a premium on the value of personal time, lifestyle, and family. By no means do I suggest that we release family physicians into training that are not ready to be competent practitioners. However, at the same time, as family medicine has seen an impressive rejuvenation in the eye of medical students - I hate to distract from this trend with the addition of a fourth year.

I suggest we give the P4 programs more time before rushing towards additional training. I further say we look to the outcomes and products of the new work hour restricted residents, before jumping to add another year. I say this, in earnest, because I think that extra year may be a huge leap in the wrong direction in the continued promotion of family medicine to medical students.

Match Day is once again upon the world of medicine, and we are eager to outline and track updates to 2012 match results for Family Medicine...

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